Welcome! Blood, guts, trauma, surgery, and life saving intervention keep us on the adrenaline roller coaster of the ER. Of course, it's not always positive. The ER can be an emotionally taxing and sometimes heartbreaking workplace, and this blog serves as an outlet for the stress of making life and death decisions each and every day.

Monday, August 15, 2011

Today a stray dog just got hit on the highway by a semi-truck, driving about 70 miles per hour. A onlooker who had witnessed the dog being hit brought it in to us (no collar, no microchip, no known owner).

He yelled and swore at ME because the dog was dead on arrival. Really?
He didn't believe that there was nothing I could do. He called me a "liar." Really?
He swore at my front office staff that we were "heartless assholes." Really?

Should I have lied to you and said that we performed CPR and brought back the dog and it was going to be all better?
Should I have lied to you and said that the dog isn't injured, and it'll be home by tomorrow?

Or should we tell you the truth? When a 40 pound dog gets hit by a semi-truck weighing somewhere in the neighborhood of 80,000lbs (2,000 times the weight of the dog), the dog loses.

It's sad, and I'm sorry, but I can't fix this one. Pretty sure that doesn't make me a liar.

Very old kitty arrives with chronic, end-stage kidney failure. The client, who is very sweet, but slightly crazy informs me that she's been feeding her cat catnip. "It's just like medicinal marijuana," she says.

Thursday, August 4, 2011

There's an expression in ER medicine - "Nice pet, nice owner = bad disease." This saying stems from the general observation that, on average, the mean, fractious, angry feral cat can survive any diagnosis, and usually has an easily fixable condition, whereas the loved, indoor only, perfectly cared for cat with loving clients who can afford the highest quality of care will end up with a terminal disease.

This case is no exception.

"Slash," a 4 year old, mostly indoor cat presented after being hit by a car just in front of his family's home. His clients tried to keep him indoors because they knew the risks of cars, of other animals, and were concerned about Slash eating birds and endangering songbird populations. Slash seemed to be unhappy in the house, and after several months, despite their better judgement, they decided to give him a couple of hours during daylight, to enjoy the greater outdoors.

The client's worst fear came true last week, when Slash ran out from underneath a car, and was hit crossing the street. He was immediately unable to walk, vocalizing and in pain. He arrived to the ER quickly, and was in shock. IV fluids were initiated, pain medication was started, and a neurologic exam was performed.

Slash was able to feel his hind limbs when pinched, but was unable to move. Radiographs were the next step at determining the cause of his injury. Pelvic fracture? Spinal trauma? Vertebral body fracture? The other abnormality on Slash's initial physical exam is that his breathing pattern was altered. It appeared as if when he breathed in, his entire chest was sucked in, instead of his chest expanding with every inward breath.

Radiographs revealed a very serious injury - Slash had a vertebral body fracture with compression of his spinal canal. He would need surgery by a specialist the following day to repair the compression, and his recovery would take time. Regardless of the cost and associated dedication to care, his family was committed to pushing forward. No other injuries were present, and with this degree of dedication, Slash had a chance at a normal life. Despite Slash's abnormal breathing pattern, there were no broken ribs to explain the pattern. He was oxygenating normally at this time, and there was nothing we could do except for watch carefully for any changes.

After Slash recovered from his shock, his status improved for a few hours before they came crashing back down. Around 3am, Slash began to have difficulty breathing and was placed on oxygen. Recheck radiographs revealed a large amount of fluid in his lungs, and a very enlarged heart. Despite lack of a heart murmur, Slash apparently had significant underlying heart disease, in addition to suspected bruising of his lungs from the trauma. He continued to deteriorate quickly, even with discontinuation of intravenous fluids and addition of diuretics. As he struggled to breathe, it became apparent that Slash was heading for disaster.

His family was contacted and wished to continue to provide every possible intervention for Slash. Slash was sedated in order to facilitate intubation and control his airway. This intervention allowed sufficient oxygen to be delivered to his body's tissues (especially the brain and heart). Fluid was dumped through his ET tube, and positive pressure ventilation was initiated.

Over the next 5 hours, we monitored Slash intensively. Slash had a dedicated technician monitoring him, and we attempted to wean him from being intubated several times, before it became obvious this was not going to be possible at any near time frame. Slash needed to be on a ventilator for 24-72 hours, or longer, to determine if he would ever again be able to ventilate his own body. Our theory and the only logical cause is that ascending spinal cord inflammation, or the direct trauma and concussion of the spinal cord, resulted in paralysis of Slash's intercostal muscles and / or his diaphragm, which resulted in failure of the body's ability to effectively ventilate. Like many neurologic injuries, there was/is no direct repair. The only option was to support his body's vital signs, and wait to see if it would ever improve. This time frame could literally be days, weeks, or never.

Unfortunately, his breathing pattern never improved. Consultation with the surgeon confirmed my exam and knowledge, and we discussed the complexities of the case with the clients for hours, while they visited with their beloved Slash.

After lots of tears, much discussion, and careful consideration, the family made the difficult decision to euthanize Slash. We were all crushed by the tragic outcome, but knew that the family had made the right decision. Slash's chance for recovery was very small, and the cost and suffering associated with that small chance would have been astronomical.

All stories contained within this blog are inspired by my life as an emergency veterinarian. Details including but not limited to name, time of visit, species, and age are changed to protect the innocent and crazy alike. Any relationship to persons or animals, living or dead, is purely coincidental.

This isn't web DVM....

These stories are shared to inspire and to entertain. They are not intended to be medical advice. If your pet is sick, the only rational thing to do is have him or her seen (in real life) by a veterinarian.

Who is that masked woman, anyway?

Ever since I was little, I always had the dream of becoming a veterinarian. The dream has been realized, and my passion is emergency medicine. ER work has many pitfalls and disadvantages, but for me, the ability to be there in a moment of crisis and help both a beloved pet and their loving family, is worth the bad days.

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Definitions and commonly seen conditions

Anemia: Low PCV (see below). Anemia can result from external hemorrhage, internal hemorrhage, destruction of blood cells in the body, or inability to make new blood cells in the bone marrow.

Azotemia: Elevation in the BUN (blood urea nitrogen) or creatinine. BUN and creatinine are body wastes typically eliminated by the kidneys; increased levels in the body indicate kidney dysfunction, obstruction of urine, or severe dehydration.

Congestive Heart Failure (CHF): Accumulation of fluid in the lungs due to failure of the heart. Some symptoms include shortness of breath, decreased appetite, rapid breathing rates, coughing, and weakness.

Feline Lower Urinary Tract disease (also called feline idiopathic cystitis): A condition resulting in frequent, painful urination, and in the most severe cases, obstruction of the urethra. FLUTD has several potential causes and is also an extreme emergency.

GDV: Gastric dilatation and volvulus. Occurs in large breed dogs; the stomach fills with gas and twists. An extreme emergency, this condition is treated with stabilization and immediate surgery.

PCV: Packed cell volume. The percentage of red blood cells contained within a given sample of whole blood. Normal for dogs and cats is typically 35%-45%.